Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anticonvulsants and Antiparkinsonism Drugs Chapter 5.
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anticonvulsants and Anticonvulsants and Antiparkinsonism Antiparkinsonism
DrugsDrugs
Anticonvulsants and Anticonvulsants and Antiparkinsonism Antiparkinsonism
DrugsDrugs
Chapter 5Chapter 5
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anticonvulsant DrugsAnticonvulsant DrugsAnticonvulsant DrugsAnticonvulsant Drugs
Prevent convulsions or seizure
Partial or focal seizure Arise from a localized area in the brain and cause specific
symptoms
Can spread to the entire brain and cause a generalized seizure
Generalized seizure Absence
Myoclonic
Tonic-clonic
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Psychomotor SeizuresPsychomotor SeizuresPsychomotor SeizuresPsychomotor Seizures
Occur most often in children.
Aura may precede the event.
Most common motor symptom is drawing or jerking of the mouth and face.
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EpilepsyEpilepsyEpilepsyEpilepsy
Permanent, recurrent seizure disorder
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Actions of AnticonvulsantsActions of AnticonvulsantsActions of AnticonvulsantsActions of Anticonvulsants
Reduce the excitability of the neurons of the brain
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Uses of AnticonvulsantsUses of AnticonvulsantsUses of AnticonvulsantsUses of Anticonvulsants
Used to control seizure activity, but often a patient will not respond well to one drug, and another drug or a combination will be tried
Dose adjustments often are needed to find the correct level of control
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Adverse Reactions of AnticonvulsantsAdverse Reactions of AnticonvulsantsAdverse Reactions of AnticonvulsantsAdverse Reactions of Anticonvulsants
The most common adverse reaction is sedation.
Can range from drowsiness to somnolence
Agitation rather than sedation may occur in some patients.
Adverse reactions may be reduced or eliminated with therapy or a decrease in dose.
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Adverse Reactions of AnticonvulsantsAdverse Reactions of AnticonvulsantsAdverse Reactions of AnticonvulsantsAdverse Reactions of Anticonvulsants Benzodiazepines also can cause sedation
Adverse reactions can be dose dependent and include:
Anorexia
Constipation or diarrhea
A health care provider should be notified if:
Unusual bruising or bleeding
Fever
Sore throat
Rash
Mouth ulcers
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Adverse Reactions of AnticonvulsantsAdverse Reactions of AnticonvulsantsAdverse Reactions of AnticonvulsantsAdverse Reactions of Anticonvulsants
Hydantoins (phenytoin) are the most commonly prescribed anticonvulsants, and adverse effects include:
Nystagmus
Ataxia
Slurred speech
Mental changes
Gingival hyperplasia
Blood dyscrasias
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Adverse Reactions of AnticonvulsantsAdverse Reactions of AnticonvulsantsAdverse Reactions of AnticonvulsantsAdverse Reactions of Anticonvulsants
Succinimides often cause gastrointestinal symptoms
Other adverse reactions:
Mental confusion
Personality changes
Pruritus
Urticaria
Urinary frequency
Weight loss
Hematologic changes
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Adverse Reactions of AnticonvulsantsAdverse Reactions of AnticonvulsantsAdverse Reactions of AnticonvulsantsAdverse Reactions of Anticonvulsants
• Miscellaneous anticonvulsants
– Lamotrigine – severe and potentially fatal rash
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of AnticonvulsantsInteractions of AnticonvulsantsContraindications, Precautions, and Contraindications, Precautions, and Interactions of AnticonvulsantsInteractions of Anticonvulsants
Care should be taken with barbiturate use in patients with liver, kidney, or neurologic disorders or pulmonary disease.
Barbiturates are used with caution in hyperactive children.
Barbiturates will have an additive effect if used with alcohol or other CNS depressants.
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of AnticonvulsantsInteractions of AnticonvulsantsContraindications, Precautions, and Contraindications, Precautions, and Interactions of AnticonvulsantsInteractions of Anticonvulsants
Care should be taken with benzodiazepine use in patients with psychoses, acute narrow angle glaucoma, liver or kidney disease, or neurologic disorders.
Benzodiazepines should be used with caution in elderly or debilitated patients.
Alcohol and other CNS depressants can also have an additive effect when used with benzodiazepine.
Benzodiazepines interact with a number of other medications.
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of AnticonvulsantsInteractions of AnticonvulsantsContraindications, Precautions, and Contraindications, Precautions, and Interactions of AnticonvulsantsInteractions of Anticonvulsants
Hydantoins are contraindicated in patients with:
Sinus bradycardia
Sinoatrial block
Second- and third-degree AV block
Adams-Stokes syndrome
Liver disease
Pregnancy and lactation
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of AnticonvulsantsInteractions of AnticonvulsantsContraindications, Precautions, and Contraindications, Precautions, and Interactions of AnticonvulsantsInteractions of Anticonvulsants
Hydantoins have an additive effect with alcohol and other CNS depressants.
Phenytoin should be used with caution in patients with:
Hypotension
Severe myocardial insufficiency
Hepatic impairment
Phenytoin interacts with many different drugs.
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of AnticonvulsantsInteractions of AnticonvulsantsContraindications, Precautions, and Contraindications, Precautions, and Interactions of AnticonvulsantsInteractions of Anticonvulsants
Succinimides are contraindicated in patients with bone marrow depression or hepatic or renal impairment and during lactation.
Additive effect with alcohol, antidepressants, and narcotics
Concurrent administration with other anticonvulsants may require a dosage adjustment.
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of AnticonvulsantsInteractions of AnticonvulsantsContraindications, Precautions, and Contraindications, Precautions, and Interactions of AnticonvulsantsInteractions of Anticonvulsants
Miscellaneous anticonvulsants are used cautiously in patients with:
Glaucoma or increased intraocular pressure
History of cardiac, renal, or liver dysfunction or psychiatric disorders
Carbamazepine
Contraindicated in patients with bone marrow suppression or hepatic or renal impairment
Interacts with several other drugs
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of AnticonvulsantsInteractions of AnticonvulsantsContraindications, Precautions, and Contraindications, Precautions, and Interactions of AnticonvulsantsInteractions of Anticonvulsants
Valproic acid
Contraindicated in patients with renal impairment
Oxcarbazepine
May exacerbate dementia
Lamotrigine
Interacts with valproic acid
Miscellaneous anticonvulsants have an additive effect when combined with CNS depressants and alcohol.
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Patient Management Issues Patient Management Issues with Anticonvulsantswith AnticonvulsantsPatient Management Issues Patient Management Issues with Anticonvulsantswith Anticonvulsants
• Dosage adjustments may be necessary during initial treatment.
• Dosage adjustments are based on patient’s response and adverse reactions.
• Medication must be taken as prescribed.
– Do not omit or miss a dose.
– Do not abruptly discontinue.
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Educating the Patient and Family Educating the Patient and Family About AnticonvulsantsAbout AnticonvulsantsEducating the Patient and Family Educating the Patient and Family About AnticonvulsantsAbout Anticonvulsants
Family may be the first to witness seizures.
Keep a record of all seizures.
Anticonvulsants control, but do not cure, epilepsy.
Support groups may be available.
Safety concerns may need to be addressed, such as driving or working conditions.
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Educating the Patient and Family Educating the Patient and Family About AnticonvulsantsAbout AnticonvulsantsEducating the Patient and Family Educating the Patient and Family About AnticonvulsantsAbout Anticonvulsants
Do not increase, decrease, or omit dose.
Blood levels may need to be monitored.
Do not abruptly discontinue.
These drugs may cause drowsiness or dizziness.
Avoid alcohol.
Carry identification indicating drug use and type of seizures.
Do not use other medications without consulting a health care provider.
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Educating the Patient and Family Educating the Patient and Family About AnticonvulsantsAbout AnticonvulsantsEducating the Patient and Family Educating the Patient and Family About AnticonvulsantsAbout Anticonvulsants
Hydantoins
Brush and floss
Make regular dental appointments for oral examination and care
Take with food
Shake the suspension before use
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Educating the Patient and Family Educating the Patient and Family About AnticonvulsantsAbout AnticonvulsantsEducating the Patient and Family Educating the Patient and Family About AnticonvulsantsAbout Anticonvulsants
Succinimides
Take with food or milk to avoid gastrointestinal upset.
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Antiparkinsonism DrugsAntiparkinsonism DrugsAntiparkinsonism DrugsAntiparkinsonism Drugs
• Parkinson disease – “paralysis agitans” is a degenerative disorder of the central nervous system
• Caused by a deficiency of dopamine and an excess of acetylcholine within the central nervous system
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Actions of Dopaminergic DrugsActions of Dopaminergic DrugsActions of Dopaminergic DrugsActions of Dopaminergic Drugs
Affect the dopamine content of the brain
Dopamine is not effective when given orally since it does not cross the blood-brain barrier.
Levodopa will cross the blood-brain barrier and then converts to dopamine.
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Uses of Dopaminergic DrugsUses of Dopaminergic DrugsUses of Dopaminergic DrugsUses of Dopaminergic Drugs
Treat signs and symptoms of parkinsonism
Levodopa is the gold standard.
Carbidopa is always given with levodopa.
Amantadine is less effective than levodopa but more effective than anticholinergics.
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Adverse Reactions of Dopaminergic Adverse Reactions of Dopaminergic DrugsDrugsAdverse Reactions of Dopaminergic Adverse Reactions of Dopaminergic DrugsDrugs
Choreiform movements
Dystonic movements
Mental changes:
Depression
Psychotic episodes
Paranoia
Suicidal tendencies
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Off–On PhenomenonOff–On PhenomenonOff–On PhenomenonOff–On Phenomenon
• Patient may suddenly alternate between improved clinical status and loss of therapeutic effect
• Associated with long-term levodopa treatment
• “Drug holiday” may be needed
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of Dopaminergic DrugsInteractions of Dopaminergic DrugsContraindications, Precautions, and Contraindications, Precautions, and Interactions of Dopaminergic DrugsInteractions of Dopaminergic Drugs
Levodopa is contraindicated in patients with narrow-angle glaucoma and taking MAOIs.
Levodopa interacts with many different drugs.
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of Dopaminergic DrugsInteractions of Dopaminergic DrugsContraindications, Precautions, and Contraindications, Precautions, and Interactions of Dopaminergic DrugsInteractions of Dopaminergic Drugs
Levodopa is used cautiously in patients with:
Cardiovascular disease
Bronchial asthma
Emphysema
Peptic ulcer disease
Renal or hepatic disease
Psychosis
Lactating patients
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of Dopaminergic DrugsInteractions of Dopaminergic DrugsContraindications, Precautions, and Contraindications, Precautions, and Interactions of Dopaminergic DrugsInteractions of Dopaminergic Drugs
Selegiline is used cautiously in patients with psychosis, dementia, or excessive tremor.
Selegiline increases the effectiveness of levodopa when they are taken together.
Selegiline interacts with fluoxetine.
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of Dopaminergic DrugsInteractions of Dopaminergic DrugsContraindications, Precautions, and Contraindications, Precautions, and Interactions of Dopaminergic DrugsInteractions of Dopaminergic Drugs
Amantadine is used cautiously in patients with:
Seizure disorders
Hepatic disease
Psychosis
Cardiac disease
Renal disease
Amantadine interacts with numerous other drugs.
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Actions and Uses of Anticholinergic Actions and Uses of Anticholinergic DrugsDrugsActions and Uses of Anticholinergic Actions and Uses of Anticholinergic DrugsDrugs
Inhibit acetylcholine in the CNS
Used as adjunctive therapy in all forms of parkinsonism
Control drug-induced extrapyramidal disorders
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Adverse Reactions of Anticholinergic Adverse Reactions of Anticholinergic DrugsDrugsAdverse Reactions of Anticholinergic Adverse Reactions of Anticholinergic DrugsDrugs Dry mouth
Blurred vision
Dizziness
Mild nausea
Nervousness
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of Anticholinergic DrugsInteractions of Anticholinergic DrugsContraindications, Precautions, and Contraindications, Precautions, and Interactions of Anticholinergic DrugsInteractions of Anticholinergic Drugs
Contraindicated in patients with:
Glaucoma
Pyloric or duodenal obstruction
Peptic ulcers, prostatic hypertrophy
Achalasia
Myasthenia gravis
Megacolon
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of Anticholinergic DrugsInteractions of Anticholinergic DrugsContraindications, Precautions, and Contraindications, Precautions, and Interactions of Anticholinergic DrugsInteractions of Anticholinergic Drugs
Use with caution in:
Older adults
Cardiovascular disease (tachycardia, cardiac arrhythmias, hypertension, hypotension)
Urinary retention
Decreased liver or kidney function
Obstructive disease of the gastrointestinal tract
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Actions and Uses of COMT InhibitorsActions and Uses of COMT InhibitorsActions and Uses of COMT InhibitorsActions and Uses of COMT Inhibitors
Catechol-O-methyltransferase (COMT) inhibitor
Thought to prolong the effect of levodopa by blocking the enzyme COMT, which would otherwise eliminate the dopamine
Used as an adjunct to levodopa/carbidopa
Easily crosses blood-brain barrier
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Adverse Reactions of COMT InhibitorsAdverse Reactions of COMT InhibitorsAdverse Reactions of COMT InhibitorsAdverse Reactions of COMT Inhibitors
Disorientation and confusion
Light-headedness
Dizziness
Dyskinesias
Hyperkinesias
Nausea and vomiting
Hallucinations
Fever
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of COMT InhibitorsInteractions of COMT InhibitorsContraindications, Precautions, and Contraindications, Precautions, and Interactions of COMT InhibitorsInteractions of COMT Inhibitors
Contraindicated during lactation
Associated with liver damage and liver failure
Used with caution in patients with hypertension, hypotension, and decreased hepatic or renal function
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Actions and Uses of Dopamine Receptor Actions and Uses of Dopamine Receptor AgonistsAgonistsActions and Uses of Dopamine Receptor Actions and Uses of Dopamine Receptor AgonistsAgonists
Exact mechanism not understood
May mimic the effects of dopamine in the brain
Used for Parkinson disease
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Adverse Reactions of Dopamine Receptor Adverse Reactions of Dopamine Receptor AgonistsAgonistsAdverse Reactions of Dopamine Receptor Adverse Reactions of Dopamine Receptor AgonistsAgonists
Nausea
Dizziness
Postural hypotension
Hallucinations
Somnolence
Vomiting
Confusion
Visual disturbances
Abnormal involuntary movements
Headache
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of Dopamine Receptor Interactions of Dopamine Receptor AgonistsAgonists
Contraindications, Precautions, and Contraindications, Precautions, and Interactions of Dopamine Receptor Interactions of Dopamine Receptor AgonistsAgonists
Contraindicated in patients with severe ischemic heart disease or peripheral vascular disease
Use with caution in patients with:
Dyskinesia
Orthostatic hypotension
Hepatic or renal impairment
Cardiovascular disease
History of hallucinations or psychosis
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Contraindications, Precautions, and Contraindications, Precautions, and Interactions of Dopamine Receptor Interactions of Dopamine Receptor AgonistsAgonists
Contraindications, Precautions, and Contraindications, Precautions, and Interactions of Dopamine Receptor Interactions of Dopamine Receptor AgonistsAgonists
Increased risk of CNS depression
Increase the effects of levodopa when coadministered
Interact with ciprofloxacin and phenothiazines
Pramipexole interacts with a number of medication
Ropinirole interacts with estrogens
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Patient Management Issues with Patient Management Issues with Antiparkinsonism DrugsAntiparkinsonism DrugsPatient Management Issues with Patient Management Issues with Antiparkinsonism DrugsAntiparkinsonism Drugs
History obtained from patient can be unreliable.
Baseline physical assessment needed.
Drug therapy needs careful monitoring.
Some patients communicate poorly.
Observe the patient for outward changes that may indicate adverse reactions.
Symptoms may be communicated through changes in posture and facial expression.
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Educating the Patient and Family Educating the Patient and Family About Antiparkinsonism DrugsAbout Antiparkinsonism DrugsEducating the Patient and Family Educating the Patient and Family About Antiparkinsonism DrugsAbout Antiparkinsonism Drugs
The home environment must be examined to make it least likely to result in accidents or falls.
Medication should be taken as prescribed.
Sudden changes in behavior can indicate hallucinations, depression, or other psychotic episodes.
Observe the patient for adverse reactions.
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